Try for free

CGS PAR 376: OPD Cervical Fusion Prior Authorization

CGS requires this request before a hospital outpatient department in Kentucky or Ohio performs cervical fusion with disc removal for an Original Medicare patient, under CMS's OPD prior authorization program. The questions test the diagnosis, imaging support, conservative treatment and the effect of symptoms on daily activities, drawing on the attending surgeon's records. The decision's UTN goes on the hospital's claim.

Who completes it

Hospital outpatient department staff complete the request with the OPD's PTAN, NPI and type of bill, the beneficiary, and the attending physician's name, NPI, fax and address, answering the clinical questions from the physician's documentation. CMS also lets a physician or practitioner submit on the hospital's behalf.

Submitting and payment

How to submit it
Submit before the service through myCGS (preferred), esMD, or by fax or mail using the Kentucky or Ohio line on the form. CGS decides in 7 calendar days, or 2 business days for justified expedited requests.
Who pays
The hospital reports the UTN on its Part A outpatient claim (type of bill 13X): an affirmed UTN means the claim will likely pay if other requirements are met, while a service billed with no UTN automatically denies.

Good to know

  • Q1 lists qualifying conditions: cervical stenosis with neurological deficit, instability, symptomatic pseudoarthrosis, adjacent or same-segment stenosis after prior surgery, trauma, tumor, infection, significant spinal deformity, or an emergency.
  • Records must include radiologic evidence or a physician's interpretation supporting the diagnosis, plus symptoms interfering with daily activities that correlate with the level affected.
  • Q3 asks whether exercise, pharmacological therapy, physical therapy or activity and lifestyle modification were attempted before surgery.
  • Originated March 26, 2021, and revised August 22, 2023. A non-affirmed fusion can also lead to denial of related anesthesia and physician claims.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization OPD: Cervical Fusion with Disc Removal

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What conservative treatment does CGS look for before cervical fusion?

Q3 asks whether conservative treatments were attempted and lists exercise, pharmacological therapy, physical therapy, and activity or lifestyle modification. A No answer means the procedure may not be considered medically necessary, so the attending physician's notes should document what was tried.

Does the CGS cervical fusion request need imaging?

Yes. Q2 asks whether the medical records include radiologic evidence or a physician's interpretation supporting the diagnosis; if not, the procedure may not be considered medically necessary. Q4 also asks that the record outline symptoms interfering with activities of daily living that correlate with the diagnosis and level affected.

What if the cervical fusion is an emergency?

An emergency situation is one of the conditions listed in Q1. Separately, CMS excludes emergency department services, billed with modifier ET or revenue code 045X, from OPD prior authorization, though those claims still undergo regular medical review.